Placenta Client Service Agreement

Placenta Client Service Agreement

Intake & Order form
Name

First Name Last Name
Phone Number

- Area Code Phone Number
E-mail
example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Support Persons Name

First Name Last Name
Support Persons Phone Number

- Area Code Phone Number

Place of Birth

Hospital Name / Home
Birth centre/ Birth suite
City	State / Province
	Country

Primary Care Provider

First Name Last Name
Primary Care Provider Number

- Area Code Phone Number
Estimated Due Date

- Month - Day Year

About Your Placenta
About Your Placenta

Your placenta is extremely nutrient rich - high in iron, protein, vitamins and minerals, including vitamin B6 and of course, your own natural hormones - making it perfectly made for you, by you. It is a deeply restorative postpartum tonic - balancing hormones, increasing milk supply, and re-building blood & Qi.

Benefits of consuming your placenta may include:
- Lessening the risk of Baby Blues
- Natural pain relief
- Stabilize post birth hormones
- Replenish depleted iron levels
- Establishing an early and healthy milk supply
- Reduce post-birth bleeding
- Replenish B vitamins and energy
The TCM Method

The TCM (traditional Chinese medicine) method is the most common way to encapsulate placenta. It has been widely reported that this method produces capsules high in quality but with a softer energy. The way the raw and TCM methods differ is an extra step in the preparation of the placenta – steaming it. This method is used to replenish warmth back to the mother that was lost in the birthing process and to rebalance the mother's Qi and energy.

I generally steam with lemon ginger & jalapenos. I can certainly exclude these if you would prefer. The herbs do add flavour. I may also use frankincense oil in the steaming process if the mother has had a particularly rough birth and can discuss these options with you.

The TCM method includes:
- Receiving and cleaning the placenta
- Steaming the placenta (with or without herbs or essential oils).This usually takes 15-20 mins each side.
- Slicing the placenta thinly in preparation for dehydration. Thiscan include the membranes and umbilical cord
- Dehydrating the placenta. This can take 24 – 36+ hours.
- Grinding the placenta into powder
- Encapsulating the powder. I use vegetarian capsules.
- Delivery to your door within 3 days of receiving your placenta.
(Please note – other steps are included at various points if additional services are requested like, for example, placenta art, cord keepsake, healing balm and placenta tincture).

Most placentas yield about 100-200 capsules. Recommended usage and care instructions are included with the placenta capsules.

Terms & Conditions
- I understand there are no current laws in Australia prohibiting me to take my placenta home.
- It is my responsibility to inform my care provider(s) of my plans to consume my placenta and ensure they are aware of how to preserve it correctly.
- I understand risks may include the placenta not being handled properly either by the hospital or myself during storage or transportation or coming in contact with chemicals in the hospital’s pathology laboratory.
- I understand any potential benefits of placenta consumption, including those suggested in research as well as anecdotally, have not been reviewed or endorsed.
- The choice to have my placenta encapsulated is based on my own personal beliefs and reasons.
- I understand Caralea Jones is not selling me a product with any verified claims or proven results, merely providing a service at my request.
- I understand Caralea Jones is not a licensed medical professional agency, and placenta services are not intended to replace medications or the advice of my health care provider(s).
- Caralea Jones adheres to the guidelines of the Australian Government Safe Food Handling and Blood Borne Pathogens regulations.
- I understand that placenta encapsulation is not currently a regulated service.
- I understand placenta capsules and most other products or services chosen will be delivered within 72 hours of Caralea Jones receiving my placenta.
- Upon receiving my placenta capsules, I waive any and all rights to holding Caralea Jones responsible for any undesired effect(s) of consuming the capsules and/or other forms of consumption I have chosen.
- I am aware it is my personal decision to ingest or discontinue taking capsules and other forms of consumption I have chosen based on either positive or negative reactions experienced.
- I understand Caralea Jones is also not liable should any other person(s) ingest my own placenta capsules or products.
- I am aware that suggested serving amounts and care instructions will be given with my package of capsules and any other services chosen.
- I understand there are instances when my placenta may not be available to me for consumption. Some examples include but are not limited to the following – uterine or amniotic infection during labour, placenta being sent to pathology, heavy meconium staining, and placenta abruption.
- I understand that if I have ever tested positive for HIV/AIDs, Hepatitis B or Hepatitis C, I should not be consuming my placenta.
- I understand that placenta services are not recommended for clients who are smokers.
- If I am in doubt about the safety of consuming my placenta due to any of the above or additional circumstances, I know I am free to consult with Caralea Jones before proceeding with any service I have chosen.
Client Responsibilities
- Talk to your care provider during a prenatal visit about your intended birthplace’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file.
- If you are birthing in a hospital: remind your care providers upon arrival that you plan to take your placenta and remind them again during 3rd stage (birthing the placenta).
- Put your placenta into a covered container, secured biohazard bag or double zip-lock bag. Please label the container or bag with your name, date and time.
- Your placenta can remain at room temperature for up to 1 hour following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.
- Do not let the placenta out of your sight. I cannot encapsulate placentas that are examined in a hospital's pathology lab. If the doctor insists on sending it to pathology, request that they only bring a small piece of the placenta to pathology, leaving the rest for you to encapsulate if deemed uninfected by pathology.
- Call or text message me 0426 988 689 after the birth to arrange a time to pick up the placenta. Please call between 7am and 10pm.
  If you are not able to contact me within 4 days of the birth, freeze the placenta until you are ready for encapsulation.
- Encapsulation takes 1-2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.
I acknowledge that by submitting this form, I am asking Caralea Jones to prepare my baby’s placenta in capsule form for my own personal use. I will be invoiced by Mumma Belly Birth Services once my form is submitted. A $50.00 deposit is payable immediately to secure my booking. The outstanding balance will be due at 38 weeks gestation. Transport fees may be higher if I live outside Canberra and surrounds.

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